Early reports of higher complication rates, specifically bile duct injuries, raised concerns over... more Early reports of higher complication rates, specifically bile duct injuries, raised concerns over the safety of laparoscopy over open cholecystectomy. This study aims to ascertain the rate, management, and perioperative outcomes of bile duct injury in an era beyond the laparoscopic learning curve. The New York State (NYS) Planning and Research Cooperative System longitudinal administrative database was used to identify patients. From 2005 to 2010, 156,315 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Patients were then tracked with unique identifiers for common bile duct injury. Common bile duct injury was identified by ICD-9 and CPT diagnosis and procedure codes for patients who subsequently underwent hepatectomy, hepaticojejunostomy, or other bile duct surgery. From 2005 to 2010, 156,958 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis o...
Obesity has a major impact on women of childbearing age. Although bariatric surgery can improve o... more Obesity has a major impact on women of childbearing age. Although bariatric surgery can improve overall health of the patient and increase fertility rates, there are unique considerations relevant to pregnancy. This chapter reviews nutritional and medical issues for all patients who are pregnant or planning pregnancy after bariatric surgery. Specific bariatric surgery complications and their management in this population are also discussed. With a multidisciplinary team, outcomes should be excellent.
The increasing prevalence of obesity translates into a greater number of obese patients undergoin... more The increasing prevalence of obesity translates into a greater number of obese patients undergoing general surgery procedures. We questioned if increased awareness and recent prophylaxis guidelines impacted the incidence of venous thromboembolism (VTE) in the obese patients. A total of 33,325 patients who underwent 4 common general surgery procedures from 2005 to 2009 were identified from the American College of Surgeons' National Surgical Quality Improvement Program database. Rates of VTE between 5 body mass index cohorts were compared with univariable analysis. No significant difference existed between rates of deep vein thrombosis or pulmonary embolism (PE) across the body mass index categories (P = .32 and P = .06, respectively). With the exception of the positive linear trend in the rate of PE for patients undergoing abdominal wall hernia repair (P < .01), there was no difference in deep vein thrombosis or PE rate exhibited by procedure. VTE rates in the obese patients a...
GERD is a significant comorbidity in bariatric patients preoperatively and postoperatively. Surge... more GERD is a significant comorbidity in bariatric patients preoperatively and postoperatively. Surgeons should be aware of appropriate evaluation, procedures choices, and management options. Revision surgery for reflux symptoms is common and appropriate anatomy and outcomes should be considered when offering these interventions to our patients. Patient selection is important to ensure avoiding postoperative development or worsening of GERD.
Perforated appendicitis has major implications on patient care. The ability of computed tomograph... more Perforated appendicitis has major implications on patient care. The ability of computed tomography (CT) scan to distinguish perforation in the absence of phlegmon or abscess is unknown. The purpose of this study is to assess the use and accuracy of CT scans in diagnosing perforated appendicitis without phlegmon or abscess. A retrospective chart review of 102 patients who underwent appendectomy from 2011 to 2013 was performed. Patient demographics and operative and postoperative course were recorded. Two radiologists were then blinded to operative findings and CT scans reread and results correlated. Findings on CT scan were also analyzed for correlation with perforation. Univariate and multivariate statistical analysis was performed. Of the 102 patients, 49 were perforated and 53 nonperforated. Analysis of patient populations demonstrated patients with perforation were significantly older (45 vs 34 years, P = 0.002), had longer operative times (132 vs 81 minutes, P = 0.001), and long...
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, Jan 6, 2014
There is an increasing trend toward morbid obesity in women of childbearing age and a subsequent ... more There is an increasing trend toward morbid obesity in women of childbearing age and a subsequent increase in number of weight reduction surgeries in these individuals. As a result, special attention needs to be paid to potential postsurgical complications during pregnancy, particularly after Roux-en-Y gastric bypass (RYGB). We are presenting our small case series and our suggestions for management for the pregnant bariatric patient. The aim of this study is to review our institutional experience and present our algorithm to approach pregnant women presenting with abdominal pain and/or emesis after RYGB. After Institutional Review Board approval, a retrospective chart review was performed at a single center institution between 2010 and 2013. Data regarding clinical presentation, physical exam findings, laboratory values, radiographic studies, intraoperative findings, and clinical outcomes of both mother and fetus were collected and reviewed for pregnant patients with history of RYGB ...
To determine the perioperative safety of esophageal fundoplication for gastroesophageal reflux di... more To determine the perioperative safety of esophageal fundoplication for gastroesophageal reflux disease (GERD) in patients with body mass index (BMI) ≥ 35 kg/m(2). A retrospective review of 4,231 patients who underwent fundoplication for GERD from 2005 to 2009 was performed. Patients were identified via National Surgical Quality Improvement Program and grouped by BMI < 35 versus BMI ≥ 35 kg/m(2). Univariate analysis compared 30-day outcomes. Of the 4,231 patients, 3,496 (83%) had BMI < 35 kg/m(2) and 735 (17%) had BMI ≥ 35 kg/m(2). Mean BMI for each cohort was 27.9 versus 39.1, respectively. Patients with BMI ≥ 35 kg/m(2) had significantly longer operative times (129.7 vs 118 minutes, P < .0001) and increased American Society of Anesthesiologists scores (2.43 vs 2.3, P = .001). The overall complication rate was 1.96%. No difference was demonstrated by BMI in complication rate or hospital length of stay. Increased American Society of Anesthesiologists score, diabetes, black r...
The ideal technique for mesenteric division to create tension-free anastomoses has not been defin... more The ideal technique for mesenteric division to create tension-free anastomoses has not been defined. For patients undergoing Roux-en-Y gastric bypass (RYGB), the mesenteric division technique was changed from stapler to bipolar sealing using LigaSure for cost reasons. This study aimed objectively to assess the impact of the mesenteric division method on mobilization length of the Roux limb in an animal model. Clinical complications related to Roux limb tension also were analyzed in the authors' population of RYGB patients. Bowel and mesenteric divisions were performed in a porcine model. Four pigs received six to eight mesenteric divisions each. Steady force was applied for 1 min. The distances between the divided limbs of bowel were compared. To assess the clinical impact with RYGB patients, anastomotic complications were analyzed before and after incorporation of bipolar sealing in the authors' practice. In the porcine model, the length of mesenteric stretch averaged 93.7 ...
As the association between sleeve gastrectomy (SG) and gastroesophageal reflux disease remains un... more As the association between sleeve gastrectomy (SG) and gastroesophageal reflux disease remains unclear, the aim of this study was to evaluate whether performance of SG impacts the development and severity of esophagitis in a rodent model. University Hospital. Wistar rats (Charles River Institute, Wilmington, MA) were fed a high fat diet (HFD) for 4 months and then were divided into 3 cohorts of nearly equal mean weight: HFD only (n = 25), sham operation+HFD (n = 29), and SG+HFD (n = 19). Animals were euthanized at 12 weeks. The esophagus was harvested en-bloc and processed for histologic assessment by a board certified pathologist, blinded to the animal treatment group. Reflux was graded by severity and defined as the presence of inflammation in the esophageal squamous mucosa. Rats who underwent SG had significantly increased reflux severity, compared with sham and HFD alone (21.1% versus 0% versus 4.5%, P = .02), respectively. No difference was demonstrated in negative, mild, or moderate esophagitis between the control, sham, and sleeve groups. Using nonparametric ANOVA, the mean severity score for severe esophagitis was significantly increased in the SG group versus sham or HFD group (1.5 versus .81 versus 1.36, P = .0202) respectively. Following multinomial logistic regression to assess for confounding variables to the severity scores, final weight, and change in weight, had no effect on severity of esophagitis between the 3 groups (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; .373). SG is independently associated with histopathologic changes consistent with severe esophagitis in an animal model, likely secondary to gastroesophageal reflux.
Bronchogenic cysts are rare foregut abnormalities that arise from aberrant budding of the tracheo... more Bronchogenic cysts are rare foregut abnormalities that arise from aberrant budding of the tracheobronchial tree early in embryological development. These cysts predominantly appear in the mediastinum, where they may compress nearby structures. Intra-abdominal bronchogenic cysts are rare. We report an intra-abdominal bronchogenic cyst that was excised laparoscopically. A 40-year old female with a history of gastritis presented for evaluation of recurrent abdominal pain. A previous ultrasound showed cholelithiasis and a presumed portal cyst. Physical examination and laboratory findings were unremarkable. A CT scan with pancreatic protocol was performed and an intra-abdominal mass adherent to the esophagus was visualized. A laparascopic enucleation of the mass was performed. A 3-cm myotomy was made after circumferential dissection of the cyst and the decision was made intraoperatively to reapproximate the muscularis layer. A PubMed literature search on surgical management of esophageal bronchogenic cysts was subsequently performed. The literature search performed on the subject of esophageal bronchogenic cysts found one review article focusing on intramural esophageal bronchogenic cysts in the mediastinum and five case reports of esophageal bronchogenic cysts. Of these, only one was both intraabdominal and managed laparascopically with simple closure of the resulting myotomy. The majority of the bronchogenic cysts mentioned in the literature were located mediastinally and were managed via open thoracotomy. Our findings confirm the rarity of this particular presentation and the unique means by which this cyst was surgically excised. This case highlights the management of a rare entity and advocates for enucleation of noncommunicating, extraluminal esophageal bronchogenic cysts and closure of the esophageal muscular layers over intact mucosa as a viable surgical approach to this unusual pathology. Other cases of laparascopic enucleation of bronchogenic cysts have shown similarly uneventful postoperative courses and rapid recovery with no apparent return of symptoms.
While surgical exploration remains the gold standard for diagnosing internal hernia (IH) after ce... more While surgical exploration remains the gold standard for diagnosing internal hernia (IH) after certain bariatric surgeries, decisions for operative intervention are often based on computed tomography (CT) findings. The aim of this study is to review our institutional experience and create an algorithm to approach patients presenting with abdominal pain and/or emesis after certain bariatric procedures. University Hospital METHODS: Following institutional review board approval, a retrospective chart review of all patients presenting with obstruction symptoms after laparoscopic Roux-en-Y gastric bypass (LRYGB) was performed at 2 institutions from 2008 to 2013. Patients without CT scans or with incidental hernia defect findings were excluded. CT and intraoperative findings were compared via univariate statistical analysis. Fifty-two patients who underwent an operation for a suspected IH were identified. Of the 50 patients, 25 (50%) had IH at operation. Twenty-nine patients (58%) had positive CT scans read for IH and/or obstruction. Of these 29, 19 (66%) were found to have IH at operation and 10 (34%) underwent negative diagnostic laparoscopy. Of the 21 patients with negative CT scans, 6 (29%) had IH at operation versus 15 (71%) who were negative. The sensitivity of CT scan to detect an internal hernia is 76% with 95% confidence interval (CI) [53% to 90%] and specificity is 60% with 95% CI [39% to 78%]. Sensitivity increased to 96% with 95% CI [78% to 99.8%] when combining CT scans with neutrophilia findings. Positive CT scans are sensitive for IH but not specific. CT scans will not detect IH in 1:4 patients; despite negative findings, surgical exploration should remain the gold standard for patients with acute abdominal pain after LRYGB or biliopancreatic diversion when IH is a consideration.
Over the past decade, there has been a rapid decline in adverse events after bariatric surgery. A... more Over the past decade, there has been a rapid decline in adverse events after bariatric surgery. As a result, it is possible that the influence of hospital volume on outcomes has attenuated over time. The objective of the present study was to examine whether the relationship between hospital volume and adverse events has persisted in the era of laparoscopic surgery. This study is based on analysis of State Inpatient Databases (SID) for 12 states from 2006 through 2011, which included 446,127 patients. Using hospital discharge data, changes in serious complications, reoperations and mortality over time, and the impact of hospital volume on outcomes among patients undergoing laparoscopic adjustable gastric band (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) were studied. Hospitals were stratified by operative volume, and using multivariable logistic regression to adjust for patient characteristics and procedure-type, the relationships between hospital volume and outcomes during 3 2-year periods were examined: 2006-2007, 2008-2009, and 2010-2011. The rate of reoperations and mortality were low, and there were no significant differences between the highest (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;125 cases/yr) and lowest (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;50 cases/yr) volume hospitals for both LAGB and LRYGB. The volume-outcome relationship was most prominent when examining rates of adjusted odds ratios for serious complications at the lowest volume hospitals compared with the highest volume hospitals (LAGB: 1.65 [CI: 1.18, 2.30] for 2006-2007, 1.81 [CI: 1.36, 2.41] for 2008-2009, and 2.08 [CI:1.40, 3.09] for 2010-2011; LRYGB: 1.55 [CI:1.23, 1.95] for 2006-2007, 1.39 [CI:1.09, 1.76], and 1.39 [CI:1.07, 1.80] for 2010-2011). Outcomes improved over the study period at both high- and low-volume volume hospitals. There remain significant differences in serious complications between the highest and lowest volume hospitals for both stapled and nonstapled procedures.
... and Non-surgical Management Rebecca P. Petersen and Aurora D. Pryor Obscure Gastrointestinal ... more ... and Non-surgical Management Rebecca P. Petersen and Aurora D. Pryor Obscure Gastrointestinal Bleeding Definitions, Causes, and Epidemiology ... 15. Lewis MP, Khoo DE and Spencer J. Value of laparotomy in the diagnosis of obscure gastrointestinal haemorrhage. ...
Many new techniques and bariatric endoluminal procedures are being developed and used for the tre... more Many new techniques and bariatric endoluminal procedures are being developed and used for the treatment of obesity. Clear guidelines or opinions of the new techniques are not readily available. The aim of this study was to gauge the level of interest and opinions of bariatric surgeons regarding these new techniques, using online and real poll surveys. The American Society for Metabolic and Bariatric Surgery (ASMBS) Emerging Technologies committee developed a questionnaire that was distributed among the membership and conducted a live poll of attendees at Obesity Week 2013. Opinions of new technologies and techniques by practitioners were assessed. A total of 134 responses to the questionnaire were returned. Most responses (79%) expressed the belief that new bariatric techniques are needed to improve the practice of bariatric and metabolic surgery. The responses describing the effects of new procedures and technology as beneficial were (1) increased interest from patients or referring physicians (94%), (2) expanded indications for intervention (93%), and (3) lower risk intervention (96%). Nearly all respondents (90.2%) identified value in informational guidelines on new technologies and procedures, and most (88.7%) agreed that the ASMBS should coordinate clinical trials or registries to evaluate these therapies. Although most bariatric and metabolic surgeons agree that new endoluminal surgical techniques are beneficial, most also are unable to offer the procedures to their patients without more clinical evidence and clear guidelines from the society.
Many practices are creating weight loss programs, in preparation for bariatric surgery or for pat... more Many practices are creating weight loss programs, in preparation for bariatric surgery or for patients who wish to lose weight without surgery. Preoperative weight loss may be associated with improved postoperative weight loss and resolution of co-morbidities. The aim of this study is to investigate the success of a preoperative weight loss program at a single institution and the variables associated with success in weight loss. We enrolled patients in a once monthly multidisciplinary preoperative weight loss program and evaluated % total weight lost over the 6-month program for primary and for revisional bariatric surgical patients. Demographic characteristics, weight, program related factors, and co-morbidities were recorded. One-way ANOVA and multiple linear regression models were carried out to assess variables. Parameter estimates of multiple linear regression models were reported. Statistical significance was set at .05 and analysis was done using SAS 9.3. A total of 133 patients enrolled and completed the program over a period of 14 months. Only 50.8% of the patients lost weight with average weight loss of .1±4.0 lbs. Patient׳s sex, insurance, psychiatric history, co-morbidities, referral status, or type of counseling had no significant effect on weight loss (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;.05). Patients between 30 and 50 years old on average were more successful in losing weight (P = .018). Patients considering revisional surgery were less successful preoperatively compared to first time candidates (P = .0007). Patients between 30 and 50 years of age, first time surgical candidates, and those with higher weights may be more successful in losing weight in a preoperative bariatric weight loss program.
ABSTRACT Laparoendoscopic single-site (LESS) surgery has emerged as a method to employ existing l... more ABSTRACT Laparoendoscopic single-site (LESS) surgery has emerged as a method to employ existing laparoscopic techniques via a single incision. The technique has gained tremendous momentum, and its feasibility has been demonstrated throughout multiple surgical disciplines. LESS may offer improved cosmesis and may have other potential advantages over conventional multiport laparoscopy. Clinical trials, some already underway, will determine if these advantages indeed accrue and how significant they are. This chapter describes basic principles and gives technical tips for success and the means by which the problems inherent in the modality may be minimized.
Early reports of higher complication rates, specifically bile duct injuries, raised concerns over... more Early reports of higher complication rates, specifically bile duct injuries, raised concerns over the safety of laparoscopy over open cholecystectomy. This study aims to ascertain the rate, management, and perioperative outcomes of bile duct injury in an era beyond the laparoscopic learning curve. The New York State (NYS) Planning and Research Cooperative System longitudinal administrative database was used to identify patients. From 2005 to 2010, 156,315 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Patients were then tracked with unique identifiers for common bile duct injury. Common bile duct injury was identified by ICD-9 and CPT diagnosis and procedure codes for patients who subsequently underwent hepatectomy, hepaticojejunostomy, or other bile duct surgery. From 2005 to 2010, 156,958 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis o...
Obesity has a major impact on women of childbearing age. Although bariatric surgery can improve o... more Obesity has a major impact on women of childbearing age. Although bariatric surgery can improve overall health of the patient and increase fertility rates, there are unique considerations relevant to pregnancy. This chapter reviews nutritional and medical issues for all patients who are pregnant or planning pregnancy after bariatric surgery. Specific bariatric surgery complications and their management in this population are also discussed. With a multidisciplinary team, outcomes should be excellent.
The increasing prevalence of obesity translates into a greater number of obese patients undergoin... more The increasing prevalence of obesity translates into a greater number of obese patients undergoing general surgery procedures. We questioned if increased awareness and recent prophylaxis guidelines impacted the incidence of venous thromboembolism (VTE) in the obese patients. A total of 33,325 patients who underwent 4 common general surgery procedures from 2005 to 2009 were identified from the American College of Surgeons' National Surgical Quality Improvement Program database. Rates of VTE between 5 body mass index cohorts were compared with univariable analysis. No significant difference existed between rates of deep vein thrombosis or pulmonary embolism (PE) across the body mass index categories (P = .32 and P = .06, respectively). With the exception of the positive linear trend in the rate of PE for patients undergoing abdominal wall hernia repair (P < .01), there was no difference in deep vein thrombosis or PE rate exhibited by procedure. VTE rates in the obese patients a...
GERD is a significant comorbidity in bariatric patients preoperatively and postoperatively. Surge... more GERD is a significant comorbidity in bariatric patients preoperatively and postoperatively. Surgeons should be aware of appropriate evaluation, procedures choices, and management options. Revision surgery for reflux symptoms is common and appropriate anatomy and outcomes should be considered when offering these interventions to our patients. Patient selection is important to ensure avoiding postoperative development or worsening of GERD.
Perforated appendicitis has major implications on patient care. The ability of computed tomograph... more Perforated appendicitis has major implications on patient care. The ability of computed tomography (CT) scan to distinguish perforation in the absence of phlegmon or abscess is unknown. The purpose of this study is to assess the use and accuracy of CT scans in diagnosing perforated appendicitis without phlegmon or abscess. A retrospective chart review of 102 patients who underwent appendectomy from 2011 to 2013 was performed. Patient demographics and operative and postoperative course were recorded. Two radiologists were then blinded to operative findings and CT scans reread and results correlated. Findings on CT scan were also analyzed for correlation with perforation. Univariate and multivariate statistical analysis was performed. Of the 102 patients, 49 were perforated and 53 nonperforated. Analysis of patient populations demonstrated patients with perforation were significantly older (45 vs 34 years, P = 0.002), had longer operative times (132 vs 81 minutes, P = 0.001), and long...
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, Jan 6, 2014
There is an increasing trend toward morbid obesity in women of childbearing age and a subsequent ... more There is an increasing trend toward morbid obesity in women of childbearing age and a subsequent increase in number of weight reduction surgeries in these individuals. As a result, special attention needs to be paid to potential postsurgical complications during pregnancy, particularly after Roux-en-Y gastric bypass (RYGB). We are presenting our small case series and our suggestions for management for the pregnant bariatric patient. The aim of this study is to review our institutional experience and present our algorithm to approach pregnant women presenting with abdominal pain and/or emesis after RYGB. After Institutional Review Board approval, a retrospective chart review was performed at a single center institution between 2010 and 2013. Data regarding clinical presentation, physical exam findings, laboratory values, radiographic studies, intraoperative findings, and clinical outcomes of both mother and fetus were collected and reviewed for pregnant patients with history of RYGB ...
To determine the perioperative safety of esophageal fundoplication for gastroesophageal reflux di... more To determine the perioperative safety of esophageal fundoplication for gastroesophageal reflux disease (GERD) in patients with body mass index (BMI) ≥ 35 kg/m(2). A retrospective review of 4,231 patients who underwent fundoplication for GERD from 2005 to 2009 was performed. Patients were identified via National Surgical Quality Improvement Program and grouped by BMI < 35 versus BMI ≥ 35 kg/m(2). Univariate analysis compared 30-day outcomes. Of the 4,231 patients, 3,496 (83%) had BMI < 35 kg/m(2) and 735 (17%) had BMI ≥ 35 kg/m(2). Mean BMI for each cohort was 27.9 versus 39.1, respectively. Patients with BMI ≥ 35 kg/m(2) had significantly longer operative times (129.7 vs 118 minutes, P < .0001) and increased American Society of Anesthesiologists scores (2.43 vs 2.3, P = .001). The overall complication rate was 1.96%. No difference was demonstrated by BMI in complication rate or hospital length of stay. Increased American Society of Anesthesiologists score, diabetes, black r...
The ideal technique for mesenteric division to create tension-free anastomoses has not been defin... more The ideal technique for mesenteric division to create tension-free anastomoses has not been defined. For patients undergoing Roux-en-Y gastric bypass (RYGB), the mesenteric division technique was changed from stapler to bipolar sealing using LigaSure for cost reasons. This study aimed objectively to assess the impact of the mesenteric division method on mobilization length of the Roux limb in an animal model. Clinical complications related to Roux limb tension also were analyzed in the authors' population of RYGB patients. Bowel and mesenteric divisions were performed in a porcine model. Four pigs received six to eight mesenteric divisions each. Steady force was applied for 1 min. The distances between the divided limbs of bowel were compared. To assess the clinical impact with RYGB patients, anastomotic complications were analyzed before and after incorporation of bipolar sealing in the authors' practice. In the porcine model, the length of mesenteric stretch averaged 93.7 ...
As the association between sleeve gastrectomy (SG) and gastroesophageal reflux disease remains un... more As the association between sleeve gastrectomy (SG) and gastroesophageal reflux disease remains unclear, the aim of this study was to evaluate whether performance of SG impacts the development and severity of esophagitis in a rodent model. University Hospital. Wistar rats (Charles River Institute, Wilmington, MA) were fed a high fat diet (HFD) for 4 months and then were divided into 3 cohorts of nearly equal mean weight: HFD only (n = 25), sham operation+HFD (n = 29), and SG+HFD (n = 19). Animals were euthanized at 12 weeks. The esophagus was harvested en-bloc and processed for histologic assessment by a board certified pathologist, blinded to the animal treatment group. Reflux was graded by severity and defined as the presence of inflammation in the esophageal squamous mucosa. Rats who underwent SG had significantly increased reflux severity, compared with sham and HFD alone (21.1% versus 0% versus 4.5%, P = .02), respectively. No difference was demonstrated in negative, mild, or moderate esophagitis between the control, sham, and sleeve groups. Using nonparametric ANOVA, the mean severity score for severe esophagitis was significantly increased in the SG group versus sham or HFD group (1.5 versus .81 versus 1.36, P = .0202) respectively. Following multinomial logistic regression to assess for confounding variables to the severity scores, final weight, and change in weight, had no effect on severity of esophagitis between the 3 groups (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; .373). SG is independently associated with histopathologic changes consistent with severe esophagitis in an animal model, likely secondary to gastroesophageal reflux.
Bronchogenic cysts are rare foregut abnormalities that arise from aberrant budding of the tracheo... more Bronchogenic cysts are rare foregut abnormalities that arise from aberrant budding of the tracheobronchial tree early in embryological development. These cysts predominantly appear in the mediastinum, where they may compress nearby structures. Intra-abdominal bronchogenic cysts are rare. We report an intra-abdominal bronchogenic cyst that was excised laparoscopically. A 40-year old female with a history of gastritis presented for evaluation of recurrent abdominal pain. A previous ultrasound showed cholelithiasis and a presumed portal cyst. Physical examination and laboratory findings were unremarkable. A CT scan with pancreatic protocol was performed and an intra-abdominal mass adherent to the esophagus was visualized. A laparascopic enucleation of the mass was performed. A 3-cm myotomy was made after circumferential dissection of the cyst and the decision was made intraoperatively to reapproximate the muscularis layer. A PubMed literature search on surgical management of esophageal bronchogenic cysts was subsequently performed. The literature search performed on the subject of esophageal bronchogenic cysts found one review article focusing on intramural esophageal bronchogenic cysts in the mediastinum and five case reports of esophageal bronchogenic cysts. Of these, only one was both intraabdominal and managed laparascopically with simple closure of the resulting myotomy. The majority of the bronchogenic cysts mentioned in the literature were located mediastinally and were managed via open thoracotomy. Our findings confirm the rarity of this particular presentation and the unique means by which this cyst was surgically excised. This case highlights the management of a rare entity and advocates for enucleation of noncommunicating, extraluminal esophageal bronchogenic cysts and closure of the esophageal muscular layers over intact mucosa as a viable surgical approach to this unusual pathology. Other cases of laparascopic enucleation of bronchogenic cysts have shown similarly uneventful postoperative courses and rapid recovery with no apparent return of symptoms.
While surgical exploration remains the gold standard for diagnosing internal hernia (IH) after ce... more While surgical exploration remains the gold standard for diagnosing internal hernia (IH) after certain bariatric surgeries, decisions for operative intervention are often based on computed tomography (CT) findings. The aim of this study is to review our institutional experience and create an algorithm to approach patients presenting with abdominal pain and/or emesis after certain bariatric procedures. University Hospital METHODS: Following institutional review board approval, a retrospective chart review of all patients presenting with obstruction symptoms after laparoscopic Roux-en-Y gastric bypass (LRYGB) was performed at 2 institutions from 2008 to 2013. Patients without CT scans or with incidental hernia defect findings were excluded. CT and intraoperative findings were compared via univariate statistical analysis. Fifty-two patients who underwent an operation for a suspected IH were identified. Of the 50 patients, 25 (50%) had IH at operation. Twenty-nine patients (58%) had positive CT scans read for IH and/or obstruction. Of these 29, 19 (66%) were found to have IH at operation and 10 (34%) underwent negative diagnostic laparoscopy. Of the 21 patients with negative CT scans, 6 (29%) had IH at operation versus 15 (71%) who were negative. The sensitivity of CT scan to detect an internal hernia is 76% with 95% confidence interval (CI) [53% to 90%] and specificity is 60% with 95% CI [39% to 78%]. Sensitivity increased to 96% with 95% CI [78% to 99.8%] when combining CT scans with neutrophilia findings. Positive CT scans are sensitive for IH but not specific. CT scans will not detect IH in 1:4 patients; despite negative findings, surgical exploration should remain the gold standard for patients with acute abdominal pain after LRYGB or biliopancreatic diversion when IH is a consideration.
Over the past decade, there has been a rapid decline in adverse events after bariatric surgery. A... more Over the past decade, there has been a rapid decline in adverse events after bariatric surgery. As a result, it is possible that the influence of hospital volume on outcomes has attenuated over time. The objective of the present study was to examine whether the relationship between hospital volume and adverse events has persisted in the era of laparoscopic surgery. This study is based on analysis of State Inpatient Databases (SID) for 12 states from 2006 through 2011, which included 446,127 patients. Using hospital discharge data, changes in serious complications, reoperations and mortality over time, and the impact of hospital volume on outcomes among patients undergoing laparoscopic adjustable gastric band (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) were studied. Hospitals were stratified by operative volume, and using multivariable logistic regression to adjust for patient characteristics and procedure-type, the relationships between hospital volume and outcomes during 3 2-year periods were examined: 2006-2007, 2008-2009, and 2010-2011. The rate of reoperations and mortality were low, and there were no significant differences between the highest (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;125 cases/yr) and lowest (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;50 cases/yr) volume hospitals for both LAGB and LRYGB. The volume-outcome relationship was most prominent when examining rates of adjusted odds ratios for serious complications at the lowest volume hospitals compared with the highest volume hospitals (LAGB: 1.65 [CI: 1.18, 2.30] for 2006-2007, 1.81 [CI: 1.36, 2.41] for 2008-2009, and 2.08 [CI:1.40, 3.09] for 2010-2011; LRYGB: 1.55 [CI:1.23, 1.95] for 2006-2007, 1.39 [CI:1.09, 1.76], and 1.39 [CI:1.07, 1.80] for 2010-2011). Outcomes improved over the study period at both high- and low-volume volume hospitals. There remain significant differences in serious complications between the highest and lowest volume hospitals for both stapled and nonstapled procedures.
... and Non-surgical Management Rebecca P. Petersen and Aurora D. Pryor Obscure Gastrointestinal ... more ... and Non-surgical Management Rebecca P. Petersen and Aurora D. Pryor Obscure Gastrointestinal Bleeding Definitions, Causes, and Epidemiology ... 15. Lewis MP, Khoo DE and Spencer J. Value of laparotomy in the diagnosis of obscure gastrointestinal haemorrhage. ...
Many new techniques and bariatric endoluminal procedures are being developed and used for the tre... more Many new techniques and bariatric endoluminal procedures are being developed and used for the treatment of obesity. Clear guidelines or opinions of the new techniques are not readily available. The aim of this study was to gauge the level of interest and opinions of bariatric surgeons regarding these new techniques, using online and real poll surveys. The American Society for Metabolic and Bariatric Surgery (ASMBS) Emerging Technologies committee developed a questionnaire that was distributed among the membership and conducted a live poll of attendees at Obesity Week 2013. Opinions of new technologies and techniques by practitioners were assessed. A total of 134 responses to the questionnaire were returned. Most responses (79%) expressed the belief that new bariatric techniques are needed to improve the practice of bariatric and metabolic surgery. The responses describing the effects of new procedures and technology as beneficial were (1) increased interest from patients or referring physicians (94%), (2) expanded indications for intervention (93%), and (3) lower risk intervention (96%). Nearly all respondents (90.2%) identified value in informational guidelines on new technologies and procedures, and most (88.7%) agreed that the ASMBS should coordinate clinical trials or registries to evaluate these therapies. Although most bariatric and metabolic surgeons agree that new endoluminal surgical techniques are beneficial, most also are unable to offer the procedures to their patients without more clinical evidence and clear guidelines from the society.
Many practices are creating weight loss programs, in preparation for bariatric surgery or for pat... more Many practices are creating weight loss programs, in preparation for bariatric surgery or for patients who wish to lose weight without surgery. Preoperative weight loss may be associated with improved postoperative weight loss and resolution of co-morbidities. The aim of this study is to investigate the success of a preoperative weight loss program at a single institution and the variables associated with success in weight loss. We enrolled patients in a once monthly multidisciplinary preoperative weight loss program and evaluated % total weight lost over the 6-month program for primary and for revisional bariatric surgical patients. Demographic characteristics, weight, program related factors, and co-morbidities were recorded. One-way ANOVA and multiple linear regression models were carried out to assess variables. Parameter estimates of multiple linear regression models were reported. Statistical significance was set at .05 and analysis was done using SAS 9.3. A total of 133 patients enrolled and completed the program over a period of 14 months. Only 50.8% of the patients lost weight with average weight loss of .1±4.0 lbs. Patient׳s sex, insurance, psychiatric history, co-morbidities, referral status, or type of counseling had no significant effect on weight loss (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;.05). Patients between 30 and 50 years old on average were more successful in losing weight (P = .018). Patients considering revisional surgery were less successful preoperatively compared to first time candidates (P = .0007). Patients between 30 and 50 years of age, first time surgical candidates, and those with higher weights may be more successful in losing weight in a preoperative bariatric weight loss program.
ABSTRACT Laparoendoscopic single-site (LESS) surgery has emerged as a method to employ existing l... more ABSTRACT Laparoendoscopic single-site (LESS) surgery has emerged as a method to employ existing laparoscopic techniques via a single incision. The technique has gained tremendous momentum, and its feasibility has been demonstrated throughout multiple surgical disciplines. LESS may offer improved cosmesis and may have other potential advantages over conventional multiport laparoscopy. Clinical trials, some already underway, will determine if these advantages indeed accrue and how significant they are. This chapter describes basic principles and gives technical tips for success and the means by which the problems inherent in the modality may be minimized.
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